appendix K – The National Academy for State Health Policy

During the COVID-19 pandemic, states have used the Appendix K Emergency Preparedness and Response authority to amend Medicaid 1915(c) home- and community-based services (HCBS) waivers and quickly provide more flexible services and supports to Medicaid enrollees and, indirectly, their caregivers.

The Appendix K amendment was developed to reduce states’ administrative burdens during a crisis by enabling states to rapidly modify or add services provided through Medicaid waivers. States can specify proposed effective dates and anticipated end dates for Appendix Ks, which are generally tied to the period of the public health emergency.

During the emergency period, states can temporarily modify waiver features, such as the types of services and providers included under the waiver, reporting requirements, payment rates and retainer payments, and modes of service delivery such as telehealth. States can also temporarily increase the unduplicated number of participants (Factor C) and make a host of other temporary changes. Appendix K provides flexibility without providing new funding to states, and states cannot use Appendix K to make changes not allowed under statute.

This report highlights examples of innovative modifications incorporated through Appendix K amendments by Connecticut, Georgia, Utah, and Washington to support older people, adults with physical disabilities, and their caregivers during the pandemic. Additional information about states’ use of Appendix K, including more information on other approaches taken by the four states highlighted below, can be found on NASHP’s interactive map of state Appendix K amendments. This map is part of NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, funded by The John A. Hartford Foundation and in collaboration with the US Administration for Community Living.

Connecticut: Maintaining Key Services while Limiting COVID-19 Exposure

Connecticut submitted multiple Appendix K amendments for multiple home- and community-based services waivers, including the Personal Care Assistance (PCA) and Home Care Program for Elders waivers, in order to leverage federal flexibility to sustain services while maintaining social distancing for especially vulnerable older adults and people with disabilities.

Through its Appendix K amendments, Connecticut is supporting remote delivery for a range of services such as adult day programs, counseling, evaluation and assessment. The state has permitted family members to receive payment for providing certain personal care-related services in the home, added home-delivered meals to the PCA waiver, and allowed additional or non-traditional home-delivered meal providers for both waivers. These changes have allowed participants to maintain connections and receive support while reducing the risk of exposure to the virus.

To help Medicaid enrollees get the long-term services and supports they need during the COVID-19 crisis, states use waivers and amendments granted by the Centers for Medicare & Medicaid Services to add flexibility in their program delivery.

Many states have used these tools to modify their home- and community-based services for older adults and their family caregivers during this crisis.

Connecticut’s Department of Social Services reports positive feedback on the changes, noting that modifications have effectively supported continuity of care for waiver enrollees. For the Home Care Program for Elders and PCA waivers, other important changes in Connecticut included temporarily allowing emergency increases in individual cost limits for current enrollees, and, within the Home Care Program for Elders waiver, allowing substitution of lower- level staff in the service plan when necessary.

Georgia: Paying for Services in Temporary Living Situations

Georgia drafted multiple combined Appendix K amendments for two of its waivers, the Elderly and Disabled waiver and the Independent Care waiver. During the emergency, among other changes, Georgia now allows family caregivers in neighboring states to receive reimbursement for providing care when the Georgia Medicaid waiver beneficiary is temporarily living with and relying on care from them during the pandemic. The state also permits family caregivers or legally responsible individuals to receive payment for providing certain personal support services and out-of-home respite. Georgia allows certain specified waiver services, including respite, to be delivered in temporary living situations, including hotels and other accommodations both in and out of state.

Utah: Allowing Payment to Nontraditional Meal and Transportation Providers

Utah used a combined Appendix K amendment to make emergency changes across seven of its waivers. Among these waivers, the Aging, Physical Disabilities, and New Choices waivers cover older adults and people with physical disabilities. Among a range of changes and flexibilities, Utah’s combined Appendix K amendments expand provider types to permit service delivery by nontraditional providers and in alternate settings. For home-delivered meal services, Utah added the ability to use delivery services such as DoorDash and UberEats in a community meal option. For non-medical transportation, the state currently allows reimbursement for non-enrolled providers, such as Lyft or Uber drivers.

Utah also expanded provider types for environmental adaptations, specialized medical equipment, and assistive technology to include the use of a purchase card to buy items from nontraditional vendors on a case-by-case basis. The state now permits direct care services, respite, day supports, and supported employment to be provided in nontraditional settings, such as churches, hotels, shelters, or the home of a direct care worker for participants who are displaced from their home due to COVID-19, or when providers are unavailable due to COVID-19. Day supports may also be allowed in an enrollee’s home. Utah also temporarily increased the unduplicated number of participants by 250 for its New Choices waiver.

Washington State: Providing a Lifeline to Adult Day Centers

To support Medicaid enrollees who rely on long-term services and supports, their family caregivers, and long-term care workers, Washington State instituted multiple Appendix K amendments to multiple waivers, including three of its home- and community-based services waivers: the Residential Support, Community Options Program Entry System (COPES), and New Freedom waivers.

Noting that key HCBS providers – such as adult day centers – that rely on face-to-face contact were at risk of shutting down, the state used Appendix K amendments to implement retainer payments during the pandemic. One official noted that the state’s ability to offer these retainer payments, and to permit day support services to be delivered both remotely and outside the adult day care setting, have been critical to maintaining care and keeping adult day centers open during the pandemic. Washington also used Appendix K amendments to, among other changes, allow up to two daily home delivered meals (in COPES and New Freedom waivers), and support the cost of Personal Protective Equipment (PPE) as part of specialized medical equipment and supplies for beneficiaries (in COPES and Residential Support waivers).

What’s Next?

While these policies are temporary, understanding the impact of these changes on the cost and quality of care for Medicaid enrollees and their family caregivers will be important in determining whether some or all of these innovations should continue after the pandemic.

States may want to consider which flexibilities provide long-term value by reviewing how reimbursement to alternative providers (such as family caregivers) and in alternate settings impacts their costs, quality, utilization, and/or waiver capacity. States may also consider how or whether newly developed infrastructure, such as telehealth, alternative providers, and service delivery mechanisms, can improve care options post-pandemic. States can also apply for a Section 1115 Demonstration opportunity to evaluate how flexibilities undertaken during the COVID-19 emergency affected the provision of care for Medicaid enrollees. States can engage Medicaid enrollees and their family caregivers to better understand impact, identify other potential innovations, and to prepare for future emergencies.

The National Academy for State Health Policy will continue to update its interactive map of state Appendix K amendments to cover policy changes that emerge as a result of the ongoing pandemic.

Updated May 7, 2020

In the past two months, 35 states* have rapidly amended their Medicaid home- and community-based services for older adults and their family caregivers to ensure access to long-term services and supports during the COVID-19 crisis. Under new federal rules, the states applied for Medicaid 1915(c) Appendix K waivers to make temporary or emergency-specific changes to protect enrollees.

Most of the states have also received approval for home- and community-based services waivers targeting other populations, such as children and people with intellectual/developmental disabilities. Of these 35 states, 19 (AK, AR, CO, DC, GA, IA, KS, KY, MA, MD, MN, MO, NM, NV, OR, SC, UT, VA, and WY) have Appendix K combination waivers that allow them to modify many waiver programs with one Appendix K application.

A Landscape of Flexibility

Overall, states are incorporating flexibilities to help Medicaid enrollees with long-term needs receive services, and some states have included flexibilities to help enrollees remain on the waivers during the emergency period. The major policy changes affect the following:

Telehealth: Nearly all of these states permit added flexibility for services, such as telehealth, or allowing services to be provided in alternative settings, such as private homes. To cut down on outsiders from entering family homes, many states are allowing for electronic and telephonic case management, service planning, evaluations, and monitoring, as well as electronic signatures or verbal approval to avoid face-to-face meetings.

Family caregiver supports: States often rely on family caregivers to provide home and community-based services to Medicaid enrollees. Recognizing this, some of these new COVID-19-related flexibilities directly assist family caregivers. Several states (AK, AZ, CA, CO, CT, DC, FL, GA, IA, KS, MS, NM, NC, ND, OK, SD, UT, and WV) are allowing family caregivers to provide services and, in some states, receive reimbursement when the hired aide is not available.

Meals and other services: To provide added support, many states (such as AZ, CO, CT, IA, KS, KY, LA, MA, MS, NC, ND, OK, SC, and UT) are expanding home-delivered meals. Several of these states (including AZ, CT, IA, MA, MS, SC, and UT) are allowing for non-traditional providers to provide the meals.

Providers: Many states are relaxing provider qualifications, including training, certification, and recertification requirements, to incorporate new, current, returning, or out-of-state providers. Several states also allow for flexibility on certain types of background checks, or qualifying relatives/family members to be direct care workers pending background checks. States (such as AK, AR, CO, DC, GA, KY, LA, MA, MS, NE, ND, OR, UT, and WA) allow for temporary payment rate increases for some providers to ensure continuity of services. Additionally, many states (such as AK, AZ, CO, DC, FL, GA, IA, KY, LA, MT, NM, NC, NY, OK, OR, UT, VA, PA, and WA) allow for retainer payments if a Medicaid enrollee or provider is not available because of COVID-19. These states often limit the payment to no more than a certain number of consecutive days, for example, 30 days.

Reporting: A number of states are loosening reporting requirements. For example, Kansas has requested a nine-month extension for its waiver reports and Oklahoma requested flexibility on its audit requirements.

State Medicaid programs have great flexibility in what services they provide and how they fund them, especially during the pandemic. For example, states can tap the temporary 6.2 percentage federal matching increase that was recently enacted in response to COVID-19. These Appendix Ks are an important tool for states because home- and community-based services waivers are serving people in the community who meet the level of care needs for services in nursing homes.

Next Steps

These policy changes are temporary, only lasting during the pandemic. After the COVID-19 crisis, it will be important to better understand the impact of these policy changes (telehealth, family caregiver supports, meals, provider flexibilities, and the ease of reporting) on cost and quality of life and determine if some of these changes should continue after the public health crisis abates.

The National Academy for State Health Policy (NASHP) developed an interactive map of state Appendix K waivers and will continue to update this information as more states make these modifications. In addition, NASHP’s RAISE Act Family Caregiver Resource and Dissemination Center, funded by The John A. Hartford Foundation and in collaboration with the US Administration for Community Living, published a report and interactive map on Medicaid information, training, and counseling resources for family caregivers.

*As of May 7, 2020, the 35 states that modified their aging and disability waivers were Alaska, Arizona, Arkansas, California, Colorado, Connecticut, Florida, Georgia, Iowa, Kansas, Kentucky, Louisiana, Maryland, Massachusetts, Minnesota, Mississippi, Montana, Nebraska, Nevada, New Mexico, New York, North Carolina, North Dakota, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Utah, Virginia, Washington State, Washington, DC, West Virginia, and Wyoming.